Dermatology Online Journal

Letter: Hyaluronic acid filler for a depressed scar
Farhan Khan¹ MD MBA, Kristen Richards² MS, Rashid M Rashid³ MD PhD
Dermatology Online Journal 18 (5): 15

1. Baylor College of Medicine, Houston, Texas
2. The University of Texas Health Science Center at Houston, Houston, Texas
3. MC Dermatology, Van Vleck, Texas

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Abstract

The use of filler for depressed scars has been documented but is rare in the literature. We present a case of a patient treated with hyaluronic acid fillers at the site of a long-standing depressed scar.

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Case report

A 54-year-old woman presented with a depressed scar on the left anterior forearm caused by insertion of metal hardware after a car accident. On examination the scar was 13 cm by 2 cm with a depression of the deepest part at 0.8 cm located on the left distal anterior forearm (Figure 1). Approximately 2 years ago, another physician injected Sculptra® at the site over 3 sessions spaced 3 months apart. The patient could not recall the exact quantity of Sculptra injected. She noted immediate aesthetic improvement of the site after injection but a return to previous appearance within 24 hours after injection. She had no other therapeutic interventions. The patient desired correction of the depressed scar and opted for hyaluronic acid filler. Approximately 2 cc Perlane®, 2 cc Restylane®, and 3 cc Juvéderm® Ultra Plus was injected into the area (Figure 2).

Figure 1	Figure 2
Figure 1. Scar prior to treatment Figure 2. Scar immediately after treatment

Figure 3
Figure 3. Scar at 2 weeks

On 2 week follow up the patient reported no complications and was quite satisfied with the filler. The scar had filled in well with no bulging, erythema, tenderness, or restriction of range of motion (Figure 3). At this time she only had some residual areas of depression near the left anterior wrist. She was treated again with 2 cc of Perlane at the depressed sites. On 8-week follow up the patient reported no complications and was quite pleased with the aesthetic results. Unfortunately, the patient was lost to follow up after her 8-week visit.

Discussion

This case demonstrates the successful use of hyaluronic acid fillers for the aesthetic improvement of depressed scars. Such treatment can be carried out safely with little risk of complications and with patient satisfaction. Hyaluronic acid fillers have been successful in case reports for the treatment of steroid atrophy [1, 2], but there are no reports of treatment of other types of depressed scars with hyaluronic acid. This case further illustrates the versatility of these fillers even at post-operative sites of trauma with no immediate or delayed complications.

The various hyaluronic acid fillers available differ in their physical characteristics, which makes them suitable for various clinical applications. Gel hardness, for instance, determines structure and stiffness. The size of the particles suspended within the gel relates to the degree of correction and volume filling. The hyaluronic acid concentration determines the longevity and stability of the filler once injected. Swelling, which refers to the gel’s ability to resist dilution, also determines longevity as well as the degree of inflammation and induration after injection. These properties together determine the behavior of the specific filler and, therefore, its clinical application [3].

The combination of hyaluronic acid fillers used for our patient allowed for a more natural contouring of the scar. Perlane and Restalyne are medium viscosity and medium elasticity fillers and were used for filling the deep depression of the scar because of its more precise sculpting. Juvéderm Ultra Plus is a low viscosity and low elasticity filler and spreads better into the tissue, leaving a softer feel [4]. Juvéderm Ultra Plus was therefore injected superficially to smooth the fine wrinkles.

Side effects of hyaluronic acid fillers include erythema, bruising, pruritus, swelling, and induration. Some case reports in the literature have also reported tissue necrosis in injected areas [5, 6]. Also, a hypersensitivity reaction resulting in a granulomatous-type response can arise and may not be evident on first use [7].

Conclusion

The use of hyaluronic acid filler for a depressed scar led to an esthetically pleasing result with patient satisfaction. This case shows that this is a viable option for the treatment of such scars.

References

1. Elliott L, Rashid RM, Colome M. Hyaluronic acid filler for steroid atrophy. J Cosmet Dermatol. 2010 Sep;9(3):253-5. [PubMed]

2. Richards KN and Rashid RM. Twenty-four month persistence of hyaluronic acid filler for an atrophic scar. Journal of Cosmetic Dermatology. 2011 10: 311-312. [PubMed]

3. Monheit GD, Prather CL. Hyaluronic acid fillers. Dermatol Ther 2006; 19: 141-50. [PubMed]

4. Sundaram H, Voigts B, Beer K, and Meland M. Comparison of the rheological properties of viscosity and elasticity in two categories of soft tissue fillers: calcium hydroxylapatite and hyaluronic acid. Dermatol Ther 2010; 36:S3: 1859-65. [PubMed]

5. Glaich AS, Cohen JL, Goldberg LH. Injection necrosis of the glabella: protocol for prevention and treatment after use of dermal fillers. Dermatol Surg 2006; 32: 276-81. [PubMed]

6. Inoue K, Sato K, Matsumoto D et al. Arterial embolization and skin necrosis of the nasal ala following injection of dermal fillers. Plast Reconstr Surg 2008; 121(3): 127e-8e. [PubMed]

7. Lupton JR, Alster TS. Cutaneous hypersensitivity reaction to injectable hyaluronic acid gel. Dermatol Surg 2000; 26(2): 135-7. [PubMed]

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